DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Monday, 11 January 2010

Some training institutions are instructing medical students and residents in performing medical procedures using 'simulated training' on special manikins. The aim of this kind of training is to teach the 'global standard' for such procedures with the expected outcome to make us 'better doctors' and to reduce mistakes made on the patients.

When techniques are taught on a 'see one, do one, teach one' basis, there is a tendency for the teacher to introduce their own variations or mistakes, which are not be in keeping with the global standard and may not have any evidence basis.

However, by doing such training in accordance with standardised procedure guidance, it is often possible to identify resident 'bad habits' e.g. failure to use local anaesthetic for performing lumbar punctures, and to then introduce how the standard techniques should be done.

One cause for confusion of junior residents has been the type of equipment and the inappropriate use of it. For example, although a chest tube comes with a central trochar, for years, it has been taught that the trochar should not be used for fear of puncturing internal organs. However, unless there is stipulation from 'trainer' that the trochar should not be used and that forceps introduction of the drain is safer, it is easy to see how wrong techniques and subsequent mistakes on patients can occur, especially if supervision of junior residents is not optimal. No junior doctor should ever be 'let loose' to 'Just Do It' without first training the doctor appropriately and ensuring that they are 'safe' for the patients. Many modern texts exclude the use of the trochar because it is dangerous. It should not be used. We need to diverge from the Eminence Based Instruction of 'this is how I learnt it and this is how I will teach it to you' concept and use Evidence and Benchmarking as much as possible, for attaining the best and most standardised technique for a particular procedure.

When performing simulation training, the trainer needs to be aware of the various global standards rather than teaching their own favoured technique, otherwise we fall into the 'see one, do one, teach many' concept that I see as being a problem as described above. There are many texts and videos now available to aid in procedure training.A recent book for 2010 is the ABC of Practical Procedures from the BMJ Press - this teaches the way procedures are taught in the UK with evidence to support certain aspects of the text. I would recommend using this book because it has clear descriptions, good pictures, and an evidence basis. However, some procedures differ to those performed in the USA ! For example, in the UK, chest drains are inserted whilst the patient is leaning forwards with the arms and head supported on a table, whereas in the USA (and Japan), such drains are generally inserted with the patient recumbent. This can indeed be a challenge to the trainer to find the best 'global' technique to teach and which has the best outcome or the best evidence for its use.

The New England Journal of Medicine produces procedures on video that can be streamed or downloaded from their website. Although these are only produced in English, they are easy to understand and can aid in training with the use of manikins and patients. In fact, all the NEJM videos are demonstrated using real life subjects.

Most recently, the iPhone AppStore has started selling Procedures Consult -- a massive multi-megabyte programme and relatively inexpensive when one compares this to a regular medical textbook or video. This software has text and video demonstrations to guide you on procedures, and I would recommend it to residents and senior doctors alike to keep refreshed on how to do techniques.

The use of evidence for procedures has helped to dispel certain ideas such as:

patients do not need iv fluid before a lumbar puncture

they do not need to lie down for several hours after a lumbar puncture -- it may in fact make a post-LP headache worse

purse string sutures no longer need to be used for chest tube insertion when withdrawing the tube; a Z incision, sealant and pressure dressings provide a better cosmetic result

local anaesthetic should be used for lumbar punctures; use of a 'small' needle is still painful

5 litres of ascites can be safely removed by paracentesis in one go without the need for using fluid replacement in liver disease. Colloid can be used in place of the traditional albumin infusions if required. There is no evidence that albumin is any better. Ascites can be removed in one session so long as there is no cardiovascular compromise. Drains are removed the same day and not left in overnight or clamped for long periods.

It is important that the students / residents have an opportunity to be observed performing the techniques after their training period. This is done to ensure good technique and that they have an understanding of the complications. Moreover, sometimes, although there is no complication, the technique does not go as planned e.g. the guidewire seems to be going up rather than down when doing a subclavian vein 'central line' cannulation. Knowing that turning the head to centre, pressing on the internal jugular vein to feel if the wire is ascending and sometimes, replacing the wire completely to get better downward angulation, can sometimes overcome the 'hiccups' of this procedure. These Procedural Pearls can be extremely helpful and are rarely printed in regular texts -- it is rare that any of these 'get out of trouble' techniques have evidence to back them up, but sometimes, they do work ! :-)

The trainee also needs to understand that it is sometimes fruitless to continue with a procedure that is going wrong. It is better to start again and / or call the senior doctor to take over. As humans, we have good days and bad days, and no one is perfect. By recognising our weaknesses as doctors, this makes us safer and stronger individuals at the same time. We then know how far we are safely prepared to go and when to refer to someone with superior technique, experience and knowledge. It is better to be cautious and careful when doing procedures than being maverick. It is the latter type of way that will end up with a disastrous outcome for the patient and for the resident.

Finally, although the modern era of technology is upon us with the use of portable ultrasonography for use in procedures, we should not forget the traditional techniques. I for one, fully support the use of ultrasonography for identifying veins from arteries and fluid from solids when doing procedure training. However, we as physicians, will not always be in a situation with technology to assist us. There was a famous situation many years ago when a person developed a tension pneumothorax whilst in-flight, and two doctors ingeniously used a coat hanger and a bottle of whiskey to make an under water chest drain. There was no x-ray technology and no ultrasonography. They used their knowledge of anatomy and procedural techniques to save a life without modern technology.

Hence, when we do simulation training, although we should teach the most up-to-date technology driven procedures e.g. ultrasonography during CV line insertion, we should also consider teaching the traditional techniques too so that the residents will be fully prepared for any event whether it is first world, third world or 30,000 feet in the air.